Provider Demographics
NPI:1679937742
Name:MIAMI PEDIATRIC GASTROENTEROLOGY LLC
Entity Type:Organization
Organization Name:MIAMI PEDIATRIC GASTROENTEROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RAGHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUTOUBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-512-3345
Mailing Address - Street 1:8525 SW 92ND ST
Mailing Address - Street 2:SUITE C-11A
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7365
Mailing Address - Country:US
Mailing Address - Phone:305-512-3345
Mailing Address - Fax:
Practice Address - Street 1:8525 SW 92ND ST
Practice Address - Street 2:SUITE C-11A
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7365
Practice Address - Country:US
Practice Address - Phone:786-270-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty